Anaesthesia and Intensive Care Journal Latest Issue

Insufflation anaesthesia and the Shipway apparatus

RN. Westhorpe, C. Ball — Sat, 01 Jun 2013 00:00:00 GMT

Postgraduate specialty training in private institutions

R. Hislop — Sat, 01 Jun 2013 00:00:00 GMT

Intensive care sedation, trends and habits

Y. Shehabi — Sat, 01 Jun 2013 00:00:00 GMT

National anaesthesia mortality reporting in Australia from 1985–2008

NM. Gibbs — Sat, 01 Jun 2013 00:00:00 GMT

This article summarises the Australian national anaesthesia mortality data from 1985–2008, previously published in eight consecutive triennial reports and covering an estimated 50 million anaesthetics. The data were obtained using consistent definitions and methodology over a 24-year period. Anaesthesia-related mortality in Australia fell from about 1:36,000 anaesthetics in the 1985–1987 triennium to about 1:55,000 for the most recent reported 2006–2008 triennium. The percentage of the deaths considered anaesthesia-caused fell from about 50% of all anaesthesia-related deaths in the 1985–1987 triennium to about 15% of all anaesthesia-related deaths in the 2006–2008 triennium. The percentage of anaesthesia-related deaths considered non-preventable (no correctable anaesthetic factor identified) increased from about 4% in the 1991–1993 triennium to about 50% in the 2006–2008 triennium. There was also an increase in the proportion of deaths in which the patient’s medical condition was considered a significant factor in the death over this period. While the trends are encouraging, they nevertheless suggest that additional efforts are required to further reduce ‘preventable’ anaesthetic deaths, and that continuing research and development into safer agents, techniques and approaches are required to reduce the incidence of deaths currently considered ‘non-preventable’.

Primary anaesthetic deaths in Western Australia from 1985–2008: causation and preventability

NM. Gibbs, P. Rodoreda — Sat, 01 Jun 2013 00:00:00 GMT

This paper reports on the causes and preventability of primary anaesthetic deaths in Western Australia between 1985 and 2008. In Western Australia, it is a legal requirement to report all deaths that occur within 48 hours of an anaesthetic and later deaths if an anaesthetic complication is implicated. A committee assesses whether an anaesthetic factor caused the death (a primary anaesthetic death) or contributed to the death (an anaesthesia-related death). Of the 2361 deaths reported to the Committee over the 24-year period, 102 were considered anaesthesia-related and of these, 53 were considered a primary anaesthetic death. There were six main causes of primary anaesthetic death: failure to oxygenate; aspiration of gastric contents; adverse drug reaction; dose-related drug effect leading to an adverse cardiovascular event; intravascular injection of local anaesthetic; and injury related to an anaesthetic procedure or invasive monitoring. The most common cause was a dose-related drug effect leading to an adverse cardiovascular event. The medical condition of the patient was considered a significant contributing factor in 69% of the deaths and 72% were considered preventable. In the second 12-year period, there were fewer deaths overall (15 vs 38), proportionately fewer deaths related to failure to oxygenate (one vs six) and proportionately more deaths related to aspiration of gastric contents (four vs two). However, the percentage of deaths considered preventable was similar. These findings can be used to advise patients on anaesthetic risks, to educate anaesthetists about preventable deaths and to encourage the development of even safer anaesthetic drugs and techniques.

The association between sedation practices and duration of mechanical ventilation in intensive care

AM. Jarman, GJ. Duke, MC. Reade, A. Casamento — Sat, 01 Jun 2013 00:00:00 GMT

Choice of sedation agent may influence duration of mechanical ventilation in the intensive care unit (ICU). We conducted a retrospective observational analysis of 2102 consecutive mechanically ventilated ICU patients over an eight-year period at a Melbourne metropolitan hospital with a ten-bed general ICU to determine if propofol was associated with shorter duration of mechanical ventilation (MV) than midazolam. Data were extracted from the hospital administrative database, pharmacy supply order records and ICU database, to calculate rates of MV and tracheostomy, length-of-stay, propofol and midazolam infusion doses, illness severity and casemix and use of ‘sedation scores’ and ‘sedation break’ respectively. The primary end-points were duration of MV, tracheostomy rate and hospital outcome. Negative binomial regression and logistic regression were used to identify temporal trends. From 1 July 2002 to 30 June 2010 there were 5751 ICU admissions including 2102 (36.6%) with MV. Over this period there was a 70% decline in annual midazolam use and a greater than fivefold rise in propofol use. ‘Sedation scoring’ and ‘sedation break’ procedures were introduced from 2006. Over the eight-year observation period there were significant increases in the numbers of annual MV admissions and long-term (>96 hours) MV patients, but a decline in median duration of MV, tracheostomy rate, median ICU length-of-stay and median hospital length-of-stay. All temporal trends were significant (P <0.05). The temporal association with changes in sedation management practice, including primary sedative agent choice during MV, may explain these findings.

The prevalence of anaemia, hypochromia and microcytosis in preoperative cardiac surgical patients

O. David, R. Sinha, K. Robinson, D. Cardone — Sat, 01 Jun 2013 00:00:00 GMT

This retrospective study aimed to determine the prevalence of preoperative anaemia, hypochromia and microcytosis in cardiac surgery patients. Data was analysed for 943 patients (over a two-year period) undergoing coronary artery bypass graft, valve or combined coronary artery bypass graft and valve surgery at a tertiary hospital in South Australia. Overall prevalence of preoperative anaemia was 25.2%, greater in males than females (27.6 vs 19.9%, P <0.01). Of patients with preoperative anaemia, 19.3% had reduced red cell indices (mean corpuscular haemoglobin and/or mean corpuscular volume) compared to 4% of patients without anaemia. The proportion of anaemic patients with low red cell indices was significantly higher in women <50 years and 50–65 years, compared to those >65 years of age (P=0.003). Anaemic patients with low red cell indices had lower preoperative haemoglobin than anaemic patients without low red cell indices (median haemoglobin 112 vs 120 g/l, P=0.008). Compared to non-anaemic patients, anaemic patients had higher transfusion rates (79.8 vs 46.4%, P <0.0001), which were greater in those with reduced red cell indices compared to those with normal red cell indices (93.5 vs 76.6%, P=0.01). This study demonstrated a high prevalence of preoperative anaemia, microcytosis and hypochromia in cardiac surgical patients.

Can the presence of significant coagulopathy be useful to exclude symptomatic acute pulmonary embolism?

KM. Ho, JA. Tan — Sat, 01 Jun 2013 00:00:00 GMT

Thrombocytopenia or an abnormal coagulation profile is not rare in hospitalised patients who have symptoms consistent with acute pulmonary embolism (PE). Theoretically, coagulopathy is more likely to occur in patients with pneumonia than acute PE. This study aimed to assess whether the presence of coagulopathy could be used to exclude acute PE in patients with symptoms and signs consistent with acute PE. In this study, a significant coagulopathy was defined as a platelet count <100×10⁹/l, an international normalised ratio >1.5, or activated partial thromboplastin time >50 seconds. Patients treated with systemic anticoagulants prior to computed tomography pulmonary angiography were excluded. Of the 986 consecutive patients who required computed tomography pulmonary angiography to exclude acute PE over a four-month period in five hospitals in Western Australia, acute PE was confirmed in 149 patients (15.1%). The incidence of coagulopathy was not significantly different between those with and without acute PE (4 vs 7%, respectively; P=0.161) and between those with and without pneumonia (8 vs 7%, respectively; P=0.505). Positive and negative likelihood ratios of coagulopathy in differentiating acute PE or pneumonia were both unsatisfactory. As a continuous predictor, platelet counts, international normalised ratio, activated partial thromboplastin time and plasma fibrinogen concentrations were also not useful in differentiating between acute PE and other pulmonary pathologies (areas under the receiver operating characteristic curve were all close to 0.5). In conclusion, the presence of significant acquired coagulopathy cannot be used to suggest pneumonia or exclude symptomatic acute PE when the prevalence or pre-test probability of acute PE is not low.

Effects of dexmedetomidine infusion on laryngeal mask airway removal and postoperative recovery in children anaesthetised with sevoﬂurane

L. He, X. Wang, S. Zheng, Y. Shi — Sat, 01 Jun 2013 00:00:00 GMT

We investigated the effects of dexmedetomidine infusion on the end-tidal concentration of sevoflurane required for smooth removal of the laryngeal mask airway (LMA) and on the incidence of respiratory complications during postoperative recovery in paediatric patients anaesthetised with sevoﬂurane. Eighty-seven patients (ASA 1 or 2, aged 3–7 years) were randomly allocated to receive saline (Group C), 0.5 µg/kg dexmedetomidine (Group D₁), or 1 µg/kg dexmedetomidine (Group D₂) after LMA insertion. A predetermined end-tidal sevoflurane concentration for each patient was determined using the Dixon’s up-and-down method (starting at 2.2% and step was 0.2%). The LMA was removed after the predetermined concentration had been maintained stable for five minutes. Sevoﬂurane minimum alveolar concentration for smooth LMA removal and postoperative recovery were assessed. The end-tidal concentration of sevoflurane required for smooth LMA removal in 50% of children (MAC_LMA-RM) in Group D₂ (0.84±0.15%) was significantly lower than in Group D₁ (1.39±0.20%; P=0.003), the latter being significantly lower than in Group C (1.73±0.14%; P <0.001). The incidence of breath-holding was significantly lower in Group D₂ (3%) than in Group C (27%; P=0.009), but comparable between Groups D₁ (17%) and C (P=0.385). The incidence of severe coughing was significantly lower in Groups D₁ (14%) and D₂ (6%) as compared to Group C (39%; P=0.005), but comparable between Groups D₁ and D₂ (P=0.323). In conclusion, dexmedetomidine infusion produced a dose-dependent decrease in the end-tidal concentration of sevoflurane required for smooth LMA removal in children and was associated less agitation in the post-anaesthetic care unit.

How do anaesthetists in New Zealand disseminate critical airway information?

PA. Baker, CL. Moore, L. Hopley, KR. Herzer, LJ. Mark — Sat, 01 Jun 2013 00:00:00 GMT

The communication of information concerning patients with difficult airways is universally recognised as an important component in avoiding future airway management difficulties. A range of options is available to impart this information; little is known however, about the follow-up patterns of anaesthetists following the identification and management of a difficult airway. In this study, 158 anaesthetists were contacted and asked to comment on their follow-up patterns regarding a number of difficult airway scenarios. This was followed by a retrospective survey of 124 patients with known difficult airways. A wide discrepancy was found between stated follow-up preferences by anaesthetists and the actual use of options such as postoperative visits, notes in the clinical record, letters to the patient and family doctor, and entries in hospital, national and MedicAlert™ databases. Of the patients with an airway difficulty noted on their anaesthetic record, only 14% of them also had a pertinent comment on their clinical record; even fewer were referred to hospital warning systems (12%) or national (6%) and MedicAlert (7%) databases. Comments from our survey were critical of multiple difficult airway databases and alert systems, which are not linked and do not lead automatically to a single source of information. We suggest that a custom-designed MedicAlert New Zealand difficult airway/intubation registry could be established, with easy access for medical practitioners and patients. This registry could be accessed through the National Health Index database and linked to the MedicAlert international registry and their nine international affiliates.

Validating a process-of-care checklist for intensive care units

KM. Conroy, D. Elliott, AR. Burrell — Sat, 01 Jun 2013 00:00:00 GMT

Early evidence suggests that checklists are one way of ensuring required processes of care are delivered to intensive care unit patients. Evidence to date however, has not explicitly detailed methods of checklist validation in these settings. This study aimed to test the validity of a ‘process-of-care’ checklist for measuring and ensuring daily care delivery in an intensive care unit. A retrospective audit of a random selection of patient medical records was undertaken to compare with checklist data completed during the same time frame. Documentation in the patients’ medical records was used as a proxy measure for actual completion of care. A specific audit tool extracted information from both the checklist and the medical record on the following processes of care: nutrition, weaning from ventilation, pain, glucose control, sit out of bed, bowel management, deep vein thrombosis and stress ulcer prophylaxis. These two data sources were compared using the Spearman’s rho correlation coefficient. The two forms of documentation were significantly correlated (P=0.01) for all but one of the checklist items (pain). Findings provided support for the concurrent validity of an intensive care unit process-of-care checklist. Further research is required for checklist validity and reliability testing prior to, or in conjunction with, a planned prospective intervention study.

Bench performance of ventilators during simulated paediatric ventilation

MAJ. Park, RC. Freebairn, CD. Gomersall — Sat, 01 Jun 2013 00:00:00 GMT

This study compares the accuracy and capabilities of various ventilators using a paediatric acute respiratory distress syndrome lung model. Various compliance settings and respiratory rate settings were used. The study was done in three parts: tidal volume and FiO₂ accuracy; pressure control accuracy and positive end-expiratory pressure (PEEP) accuracy. The parameters set on the ventilator were compared with either or both of the measured parameters by the test lung and the ventilator. The results revealed that none of the ventilators could consistently deliver tidal volumes within 1 ml/kg of the set tidal volume, and the discrepancy between the delivered volume and the volume measured by the ventilator varied greatly. The target tidal volume was 8 ml/kg, but delivered tidal volumes ranged from 3.6–11.4 ml/kg and the volumes measured by the ventilator ranged from 4.1–20.6 ml/kg. All the ventilators maintained pressure within 20% of the set pressure, except one ventilator which delivered pressures of up to 27% higher than the set pressure. Two ventilators maintained PEEP within 10% of the prescribed PEEP. The majority of the readings were also within 10%. However, three ventilators delivered, at times, PEEPs over 20% higher. In conclusion, as lung compliance decreases, especially in paediatric patients, some ventilators perform better than others. This study highlights situations where ventilators may not be able to deliver, nor adequately measure, set tidal volumes, pressure, PEEP or FiO₂.

Has the middle-level anaesthesia manpower training program of the West African College of Surgeons fulfilled its objectives?

CO. Bode, J. Olatosi, G. Amposah, I. Desalu — Sat, 01 Jun 2013 00:00:00 GMT

An audit of the West African College of Surgeons’ middle-level Diploma in Anaesthesia program was carried out to determine the current status of the diplomates. Using the West African College of Surgeons’ database, social media and personal communications, the current status of Diploma in Anaesthesia graduates spanning 20 years was determined. A total of 303 (97%) out of 311 of graduates were traced. Eighty percent were still practising anaesthesia, while 5% were now in other disciplines. Two hundred and four (67.3%) still resided in West Africa (183 in Nigeria, 50 in Ghana, one in Sierra Leone), while 69 (22.7%) were abroad: 35 (11.5%) in the United Kingdom, 21 (6.9%) in the United States of America and four (1.3%) in Canada. More Ghanaian than Nigerian graduates had emigrated (41 vs 14%, respectively). Only 9% of diplomates remained in rural communities (as originally envisaged), while 31% were now consultants (as fellows) and 30% were registrars in fellowship training. These findings indicate that most diplomates moved on to acquire further qualifications and a significant proportion migrated. The program did not appear to have achieved the objectives of meeting rural middle-level manpower needs in anaesthesia as envisaged. It has, however, boosted the recruitment drive for residency training in anaesthesia. Perhaps a less migrant cadre such as nurses may better serve this function if recruited into a suitably designed training program in countries desiring to use middle-level manpower in anaesthesia.

Outcomes in critical care delivery at Jimma University Specialised Hospital, Ethiopia

ZA. Smith, Y. Ayele, P. McDonald — Sat, 01 Jun 2013 00:00:00 GMT

The aim of this study was to assess outcomes following intensive care unit (ICU) admissions at Jimma University Specialised Hospital, Ethiopia. This was a retrospective observational study. Data were collected regarding all ICU admissions and discharges during a 12-month period beginning August 2011. Demographic data and information regarding diagnosis, length-of-stay and outcome were gathered and data analysed. There were 370 admissions to the ICU during the study period. Median age (interquartile range) was 32.0 (22.0–47.0) years and 56.2% were males. The median length-of-stay (interquartile range) was 3.0 (1.0–7.0) days. The overall ICU mortality rate was 50.4% and major causes included trauma, cardiac disease, acute abdominal presentations, septic shock, tetanus and hysterectomy secondary to uterine rupture. Medical diagnoses accounted for 50.1% of admissions followed by surgery (43.2%) and obstetrics (5.8%). Corresponding mortality rates were 53.6, 48.0 and 42.9%, respectively. The main cause for surgical admission was trauma, with head injury carrying a mortality of 52.1%. The principal cause for medical admission was cardiac disease. In children, trauma, upper airway obstruction and communicable diseases were most common. Critical care mortality rates at this Ethiopian university hospital reflect the challenges facing critical care delivery in the developing world. Delayed presentation to hospital secondary to poor access to healthcare plays a predominant role. This is confounded by inadequate staffing, training, diagnostic and interventional limitations. Despite resource restraints, simple cost-effective measures may improve morbidity and mortality.

A survey of patient understanding and expectations of sedation/anaesthesia for colonoscopy

N. Chatman, JR. Sutherland, R. van der Zwan, N. Abraham — Sat, 01 Jun 2013 00:00:00 GMT

One hundred and fifty-nine adult patients undergoing elective colonoscopy in a major regional hospital were surveyed regarding their perceptions and expectations of sedation/anaesthesia for this procedure. The survey was undertaken on the day of the procedure, but before their assessment by the anaesthetist. Most of our patients expected to be completely unconscious and few understood that there was any chance of being aware during any part of their colonoscopy procedure. The perception (level of knowledge) of patients about their sedation/anaesthesia was highly variable, and was influenced both by having had a prior colonoscopy and by having had a discussion with an anaesthetist prior to the day of procedure. Of a range of potential adverse outcomes, procedural awareness generated the highest level of concern. However, those patients who recognised the potential for procedural awareness reported significantly less concern about this potential occurrence than patients who were unaware of the possibility. Our findings suggest that explicit discussion of the possibility of procedural awareness during colonoscopy should be considered by clinicians who administer sedation or anaesthesia for colonoscopy. Knowledge of this potential source of patient confusion and anxiety may enable clinicians to better target the pre-procedural discussion, in order to more appropriately inform patient expectations.

A survey of the management of neuromuscular blockade monitoring in Australia and New Zealand

S. Phillips, PA. Stewart, AB. Bilgin — Sat, 01 Jun 2013 00:00:00 GMT

This survey of anaesthetists in Australia and New Zealand aimed to investigate their attitudes and practice relating to the management of neuromuscular blockade monitoring. All medical practitioner members (3188) of the Australian and New Zealand Societies of Anaesthetists were invited to complete an anonymous survey, which was available online for two months. A total of 678 survey questionnaires were completed (response rate 21%). Most respondents (71.4%) underestimated the incidence of residual neuromuscular blockade and 63.2% believed this to be a significant clinical problem. Objective monitoring of neuromuscular function was used routinely only by 17% of respondents, although 70% believed routine monitoring would reduce the incidence of residual neuromuscular blockade. Only 25% of respondents correctly indicated that quantitative train-of-four counts of greater than 90% were the accepted criteria for safe extubation, with 52% using clinical judgement only. Only 29% of respondents believed neuromuscular function monitors should be part of minimum monitoring standards; quantitative neuromuscular function monitors were not available in 42% of the hospitals in which the respondents practiced. Despite the low response rate, the large sample size and heterogeneity of respondents make the findings of this survey concerning. There is a need for more education, availability of appropriate monitoring equipment and evidence-based guidelines for management of neuromuscular blockade in Australia and New Zealand.

Donation after cardiac death in non-survivable burns

NJ. Widdicombe, A. Van Der Poll, A. Gould, N. Isbel — Sat, 01 Jun 2013 00:00:00 GMT

Major burns have previously been considered a contraindication to solid organ donation. We present two cases of successful organ donation and transplantation, after Maastricht category III cardiac death in adult patients with non-survivable burns injury. The implications of the outcome of these cases are that major burns should not be considered a contraindication to organ donation, and that cardiac death provides opportunity for patients with non-survivable burns to contribute to the pool of potential organ donors.

Post-cardiac surgery thrombotic thrombocytopenic purpura with digital ischaemia

L. Weinberg, J. Chang, P. Hayward, M. Reynolds, J. Fernandes — Sat, 01 Jun 2013 00:00:00 GMT

We report a case of thrombotic thrombocytopenic purpura in a woman post mitral valve repair who presented with unexplained thrombocytopenia, intermittent fever, acute renal failure and severe digital ischaemia. The diagnosis of thrombotic thrombocytopenic purpura was confirmed after exclusion of many of the aetiological factors of postoperative digital ischaemia, a positive haemolytic screen and blood film examination which showed schistocytes and fragmented red cells. Plasma ADAMTS-13 activity measured by enzyme-linked immunosorbent assay was reduced. Treatment of thrombotic thrombocytopenic purpura with exchange plasmapheresis and methylprednisolone was of paramount importance and the patient was discharged home on day 30 with complete recovery of haematological, neurological and renal function. In order to increase the awareness of this rare multisystem process, we report our experience in managing this life-threatening condition. Our discussion covers the diagnostic challenges, theories on aetiology, pathogenesis and treatment of this condition in the context of cardiac surgery.

Intraoperative awake tracheal intubation using the Airway Scope™ in caesarean section

N. Kariya, K. Kimura, R. Iwasaki, R. Ueki, T. Tatara, C. Tashiro — Sat, 01 Jun 2013 00:00:00 GMT

The Airway Scope™, a novel videolaryngoscope used for tracheal intubation, is minimally invasive and can be used in conscious patients. The parturient with a potentially difficult airway should sometimes be intubated while awake, without anaesthesia or neuromuscular block. Two pregnant women who experienced massive postpartum haemorrhage during caesarean section underwent unscheduled intraoperative tracheal intubation using the Airway Scope. They were conscious and were intubated with minimal local anaesthesia so as to prevent cardiovascular compromise. We believe the Airway Scope is useful for anaesthetic procedures in the parturient who has haemodynamic instability.

Spontaneous intracranial hypotension and epidural blood patch: a report involving seven cases

F. Ferraro, E. Marano, J. Petruzzi, E. Tedeschi, L. Santulli, A. Elefante — Sat, 01 Jun 2013 00:00:00 GMT

Spontaneous intracranial hypotension is a rare condition caused by spontaneous cerebrospinal fluid leak. It is characterised by orthostatic headache, diffuse pachymeningeal enhancement on brain imaging and low cerebrospinal fluid pressure. Seven patients with spontaneous intracranial hypotension were treated conservatively: of these, four responded to drug treatment and three underwent a lumbar autologous epidural blood patch (EBP). A complete response was obtained in two patients after a single EBP; one patient underwent a second EBP and then became asymptomatic. Clinical improvement coincided with a dramatic reduction of pachymeningeal enhancement. The aetiology and brain imaging findings, and the technique and effectiveness of EBP are discussed.

Abstracts from the Australian Pain Society's 33rd Annual Scientific Meeting 2013

. Australian Pain Society — Sat, 01 Jun 2013 00:00:00 GMT

Pre-admission processes and opportunities for improvement

JR. Sutherland, GL. Ludbrook — Sat, 01 Jun 2013 00:00:00 GMT

Pre-admission processes and opportunities for improvement—Reply

R. Kerridge — Sat, 01 Jun 2013 00:00:00 GMT

Failed intubation and oxygenation in a child

D. Borshoff — Sat, 01 Jun 2013 00:00:00 GMT

Failed intubation and oxygenation in a child—Reply

AS. Santoro, MG. Cooper — Sat, 01 Jun 2013 00:00:00 GMT

Anaesthesia training in a private healthcare facility

B. Gelbart, B. Creati — Sat, 01 Jun 2013 00:00:00 GMT

Accidental intra-arterial dexmedetomidine injection in postoperative ward

T. Ghatak, S. Samanta — Sat, 01 Jun 2013 00:00:00 GMT

Dynamic ultrasound-guided, short axis, out-of-plane radial artery cannulation: the ‘follow the tip’ technique

SL. Goh, CO. Tan, L. Weinberg — Sat, 01 Jun 2013 00:00:00 GMT

C-MAC™ Storz^® videolaryngoscope for checking vocal cord mobility following thyroidectomy

NR. Gupta, S. Kumar, K. Chaudhary, R. Kumar — Sat, 01 Jun 2013 00:00:00 GMT

Sugammadex and general anaesthesia in a patient with Brugada syndrome

A. Langley, M. Davie — Sat, 01 Jun 2013 00:00:00 GMT

Digoxin prescription in the critically ill: an unpredictably loaded problem?

B. Mrara, JA. Roberts, J. Gowardman — Sat, 01 Jun 2013 00:00:00 GMT

Serum lactate dehydrogenase as an early marker of posterior reversible encephalopathy syndrome: keep your eyes open on the score of severity brain oedema

M. Vargas, G. Servillo — Sat, 01 Jun 2013 00:00:00 GMT

Delirium and Takotsubo cardiomyopathy following cardiac surgery

LW. Wang, PC. Jansz, DW. Baron — Sat, 01 Jun 2013 00:00:00 GMT

Recycled and simplified anaesthesia machines for medical missions

IJ. Woodforth — Sat, 01 Jun 2013 00:00:00 GMT

A description of recyclying and modifying discarded Ulco Elite anaesthesia machines to make them robust and easily serviced for use on medical missions.

A Visual Guide to Anesthesia Procedures

T. McIver — Sat, 01 Jun 2013 00:00:00 GMT

Critical Care Management of the Obese Patient

M. Corkeron — Sat, 01 Jun 2013 00:00:00 GMT

Obstetric Anaesthesia

AW. Ross — Sat, 01 Jun 2013 00:00:00 GMT

Principles and Practice of Regional Anaesthesia, 4th edition

G. Frawley — Sat, 01 Jun 2013 00:00:00 GMT